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gastric bypass and methadone or other meds

AnonymousUserAAnonymousUser Posts: 49,578
edited 06/11/2012 - 7:31 AM in Health Insurance Issues
My insurance denied my gastric bypass due to using methadone for back pain. Need feedback !!!!!!!!


  • You should check with your doc. Maybe the methadone has adverse effects on the bypass? Sorry, that is all that I can think of.
  • I had to hound the insurance company and ask to speak to supervisors and stuff to get help to get approved. I told all of them that I would do whatever I had to do to get approved, just tell me the process. They weren't real helpful, but I did finally get the lowdown and I sent in everything they needed. I also wrote a personal letter stating my feelings, problems, and why having the surgery was so important to me. I got approved after that. I don't remember anything about my current medications being asked about. Did they say why that was a big deal? Did they think you wouldn't do well due to your pain level from your back? Seems like the weight loss would help just a bit on the pain. The one thing that I've found though (hate to give you another negative thought), but I've had more problems since having the bypass....from the calcium deficiency, anemia, and my osteoarthritis. I'm 44 and even though I lost over 100lbs and have kept it off, I'm not sure that I feel more healthy. But who's to say that if I hadn't had the GB that I wouldn't be in the same place anyway.

    Fight! Fight! Fight! Find out what to do to appeal the decision. Get the doctor that has prescribed the methadone to write a letter stating why and if they think the GB would be a benefit to you. My GP totally supported my decision to have one. Good luck!
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    Post Edited by Moderator haglandc
  • SpineAZSpineAZ WiscPosts: 1,084
    Work with your physician's office to appeal based on the medical necessity of the procedure you are requesting AND the medical necessity and verified treatment value of the medication you are taking. The insurance company may not understand that methadone is for pain management, they may instead be viewing it as related to an addiction problem. The surgeon you want to do the procedure has to tell the insurance company you need the surgery and how you can manage going forward with methadone or perhaps a new mediation needs to be considered (perhaps methadone is not well tolerated in gastric bypass patients).

    I think you have a good chance at appeal if your doctor can submit a strong case of medical necessity, methadone necessity for pain (not for addiction), etc. Usually a surgeon's office has staff dedicated to insurance and well versed in how to appeal and even customize their approach to different insurance companies.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
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